Utilization Management Registered Nurse - Clinical Claims Review

Description

The Utilization Management Nurse applies a Person-Centered approach, works within specific guidelines and procedures; applies advanced technical knowledge and clinical criteria to solve moderately complex problems.

Responsibilities

The Utilization Management Nurse 2 uses clinical knowledge, communication skills, and independent critical thinking skills to interpret criteria, policies, and procedures to provide the best and most appropriate treatment, care or services for members. Coordinates and communicates with providers, members, or other parties to facilitate optimal care and treatment. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations. Requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.

Essential Functions and Responsibilities

• Perform complex clinical reviews to support Utilization decisions and support claims processes.

• Understand and apply standard utilization management criteria including MCG and/or Interqual.

• Document clinical reviews, application of clinical criteria and decisions clearly using standard tools and clinical documentation systems.

• Follow utilization management policies and procedures to ensure compliance with state and federal requirements and incorporate industry best practices

• Collaborate with internal departments, providers, and community partners to support the delivery of high-quality utilization management services

• Complete education and self-development activities per Humana Healthy Horizons and department requirements.

• Must be passionate about contributing to an organization focused on continuously improving consumer experiences

               

Required Qualifications

• Licensed Registered Nurse, RN, in the state of Oklahoma without restrictions or disciplinary actions

• 3 - 5 years of Medical Surgery, Heart, Lung, Emergency Room or Critical Care Nursing experience required

• Working knowledge of MS Office including Word, Excel, PowePoint, and Teams in a Windows based environment and an ability to quickly learn new systems and ability to troubleshoot and resolve basic technical difficulties in a remote environment.

• Ability to work independently under general instructions and with a team

Additional Requirements/Adherence

Workstyle: Remote work at home

Preferred Location: Oklahoma

Alternate Locations: United States

Training Schedule: Must be able to attend training schedule. Monday - Friday; 8:00am - 5:00pm Central Time

Schedule:

• Must be able to work a 40-hour work week, Monday through Friday, 8:00 AM to 5:00 PM Central Time

• Over-time and weekends may be requested to meet business needs. Leader will discuss during interview.

Travel:

Must be willing to commute about 5-10% to meet with providers or staff meetings. More information will be provided during the interview.

Work at Home Guidance

• Must have accessibility to hardwired high speed internet with minimum speeds of 25Mx10M for a home office (Wireless and Satellite are prohibited)

• Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.

• Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.

• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Preferred Qualifications

• Bachelor's degree

• Managed Care / Health Plan experience

• Previous Medicare/Medicaid Experience

• Bilingual preferred

• Previous experience in utilization management, case management, discharge planning and/or home health or rehab

• Experience working with MCG or Interqual guidelines

• Working knowledge using the following systems/platforms CGX, MHK, Maccess, CAS,

Additional Information:

Interview Format

As part of our hiring process for this opportunity, we will be using an exciting screening and interviewing technology called Modern Hire to enhance our hiring and decision-making ability. We use this technology to gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.

You will be able to respond to the recruiters preferred response method